Provider Demographics
NPI:1447397427
Name:FOSTER, MICHAEL E (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
Last Name:FOSTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:FOSTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 315
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5036 GOODMAN RD
Practice Address - Street 2:SUITE #116
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-7966
Practice Address - Country:US
Practice Address - Phone:662-420-7061
Practice Address - Fax:662-420-7583
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11681208600000X
TN18383208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018625Medicaid
MSB64956Medicare UPIN
MSB64956Medicare UPIN